three different models for combining vertical and horizontal integration in the UK

Discussion paper

Combined horizontal and vertical integration of care: a goal of practice-based commissioning Paul Thomas FRCGP MD Clinical Director, Ealing Primary Care Trust and Professor, Thames Valley University, London, UK

Geoffrey Meads PhD MSc MA(Oxon) Visiting Professor, Southampton and Winchester Universities and Professor of Organisational Research, Institute of Health Sciences Research, Medical School, University of Warwick, Coventry, UK

Ahmet Moustafa MA MSc RN Principal Lecturer (Emeritus), Centre for the Study of Policy and Practice in Health and Social Care, Faculty of Health and Human Sciences, Thames Valley University, London, UK

Irwin Nazareth FRCGP PhD Professor of Primary Care and Population Sciences and Director MRC General Practice Research Framework, University College London Medical School, London, UK

Kurt C Stange MD PhD Editor, Annals of Family Medicine and Professor of Family Medicine, Epidemiology and Biostatistics, Sociology and Oncology, Case Western Reserve University, Cleveland, Ohio, USA

Gertrude Donnelly Hess MD Professor of Oncology Research and Professor of Family Medicine, Epidemiology and Biostatistics, Sociology and Oncology, Case Western Reserve University, Cleveland, Ohio, USA

ABSTRACT

Practice-based commissioning (PBC) in the UK is

intended to improve both the vertical and hori- zontal integration of health care, in order to avoid

escalating costs and enhance population health.

Vertical integration involves patient pathways to

treat named medical conditions that transcend

organisational boundaries and connect community-

based generalists with largely hospital-sited special-

ists, whereas horizontal integration involves peer-

based and cross-sectoral collaboration to improve overall health.

Effective mechanisms are now needed to permit

ongoing dialogue between the vertical and horizon-

tal dimensions to ensure that medical and non-

medical care are both used to their best advantage.

This paper proposes three different models for

combining vertical and horizontal integration – each is a hybrid of internationally recognised ideal

types of primary care organisation. Leaders of PBC

should consider a range of models and apply them

in ways that are relevant to the local context.

General practitioners, policy makers and others

whose job it is to facilitate horizontal and vertical

integration must learn to lead such combined ap-

proaches to integration if the UK is to avoid the mistakes of the USA in over-medicalising health issues.

Keywords: integrated healthcare systems, practice- based commissioning, organisation, organisational

objectives, primary health care

Quality in Primary Care 2008;16:425–32 # 2008 Radcliffe Publishing

P Thomas, G Meads, A Moustafa et al426

Introduction

Practice-based commissioning (PBC) in the UK National Health Service (NHS) is an attempt to plan

the best possible health care for entire populations (see

Box 1). 1

PBC will provide a local planning facility,

led by general practitioners (GPs), to complement the

systems-wide perspective of primary care trusts (PCTs).

Together they will administer NHS funds for the

population served. 2

In order to plan best care, PBC must enable com- prehensive integration of healthcare effort. Vertical

integration involves patient pathways to treat named

medical conditions, connecting generalists and spe-

cialists, whereas horizontal integration involves broad-

based collaboration to improve overall health. 3

Com-

prehensive integration includes a good balance of both.

Box 2 summarises the features of these two different

types of integration. Broadly speaking, in terms of its data sources and status, vertical integration is the

domain of medicine – diseases are researched as discrete

entities; linear care pathways consider one disease at a

time; discrete treatment packages are costed and eval-

uated for their anticipated effects; quality assurance

emphasises achievement of quantifiable outcome tar-

gets. Broadly speaking, horizontal integration is the

domain of social sciences – multidisciplinary teams and interagency collaboratives learn, inquire and inno-

vate together; cross-organisational planning leads to a

synchrony of effort that creates environments for health;

quality assurance emphasises mechanisms whereby broad

groups of stakeholders can examine whole systems of

care for their diffuse and unexpected long-term effects

and then act for co-ordinated quality improvements.

Specialist treatment for cancer requires vertical inte- gration to ensure that best treatments are given, whereas

end-of-life care requires horizontal integration to

ensure co-ordinated support from all involved. Treat-

ment of severe mental illness requires vertical integra-

tion for generalist and specialist medical practitioners

to work together in the best way, whereas horizontal

integration is needed to create environments that will

develop confident creative citizens. Commissioning must prioritise both dimensions.

GPs are naturally placed to work in the horizontal

plane since they have a traditional orientation towards

families and communities as well as individuals. How-

ever, targets such as those contained in the NHS Quality Outcomes Framework since 2003, ceaseless structural

changes, and the increasingly part-time nature of general

practice are making it difficult to sustain this orien-

tation. Furthermore, GPs have been trained in medical

science and are concerned with the micro-economics

of small enterprises – both of these appeal for their

explanatory frameworks to simple and direct assump-

tions about how a ‘cause’ has an effect (known as the science of positivism).

4 GPs consequently have little

exposure to social science evidence that broader change

is not straightforward: 5

future developments cannot

be predicted in the simple way that their training will

lead them to assume. Instead multiple factors constantly

interact and adapt to each other to shape a general trend,

as assumed by the science known as constructivism. 4

Hidden interconnected factors dominate people’s behav- iour, more powerful than the simple explanations

people use, as assumed by the science known as critical

theory. 4

Without a good grounding in these profound

and non-linear sciences, PBC is more likely to produce

integrated medical systems, rather than integrated health

systems.

Combined vertical and horizontal integration: a holy grail

The need to integrate health systems (called ‘compre-

hensive primary health care’) was agreed at the World

Health Organization (WHO) Alma Ata conference of

1978. To achieve this level of integration, healthcare

policy must be underpinned by the three principles of

participation, equity and intersectoral collaboration. 6

However, political and practical obstacles meant that

this did not happen. 7

In this year of the 30th anniversary of Alma Ata,

comprehensive primary health care is again being

seriously considered, with a major new WHO declar-

ation scheduled. Consequently healthcare reforms in

How this fits in with quality in primary care

What do we know? We know how to measure and incentivise care for specific diseases (vertical integration). We know the

importance of fostering primary care and public health (horizontal integration).

What does this paper add? This paper adds new information on how vertical and horizontal integration of care can be combined to

optimise the health care and health of people and populations.

Combined horizontal and vertical integration of care 427

Box 1 Vision, aims and organising framework for practice-based commissioning

The vision, aims and organising framework for practice-based commissioning are described in: Health Reform in England: update and commissioning framework, Department of Health, July 2006:

1

Vision (p.5) ... we have a clear vision: to develop a patient-led NHS that uses resources as effectively and fairly as possible,

to promote health, reduce health inequalities and deliver the best and safest possible care.

Aims (pp.21–2) To provide the opportunity for more effective commissioning that will over time lead to:

. improvement in health and well being

. reduction in health inequalities and social exclusion

. better access to a comprehensive range of services

. improved quality, effectiveness and efficiency of services

. increased choice for patients and better experience of care

. improved integration of health and social care.

Organising framework (pp.6–7) This will be delivered by ensuring:

. more choice and a stronger voice for patients and service users who will be able, in consultation with their

clinicians, to choose the highest quality of care appropriate for their needs . practices and PCTs as commissioners using their knowledge of local communities and extensive public

and patient involvement to get the best value within available resources. Commissioners working to improve the health of their population, reduce health inequalities, guarantee choice and secure the best

possible services. An NHS that works in partnership with local authorities and other local services to

deliver improvements and to promote equality, inclusion and respect . more freedom for providers to innovate and improve services in response to the needs and decisions of

patients, GPs and commissioners. Further expansion of NHS Foundation Trusts; a continuing role for PCT

direct provision; more opportunities for voluntary sector, social enterprise and private sector providers ... . clinicians and other staff leading change ... . effective management of the system, backed by regulation that assures national core standards and focuses

interventions on services most in need . a financial framework, including tariffs, that incentivises improvements in patient care, supports the

development of care integrated around patient need (especially long-term care needs) and promotes

financial responsibility and best value within allocated resources . extensive, comparable information on the quality and safety of care. This will give patients and

commissioners a real understanding of the choices available to them, practices the capability to track

and plan care across the whole patient pathway, and providers a proper understanding of their activity and

quality of care.

Box 2 Features of vertical, horizontal and comprehensive integration

The terms ‘vertical’ and ‘horizontal’ relate to the idea that diseases are treated at different (vertical) levels

of specialisation, whereas environments that more broadly support health require co-ordinated effort and collaborative planning at the (horizontal) level of whole people and communities. Whole system, or comprehensive,

integration requires that vertical and horizontal integration develop in tune with each other.

The distinction between these dimensions is important because different techniques are needed to achieve

them, and they draw on different theories of change and leadership. Vertical integration draws particularly on

natural science, with an emphasis on laboratory (especially positivist) research and linear care pathways.

Horizontal integration draws particularly on social science (especially critical theory) with an emphasis on

the hidden and interconnected phenomena within specific contexts. Whole-system integration draws particularly

on theories about organisational learning (especially constructivist science) that emphasise the ongoing adaptation that happens between interacting factors through mutual learning.

Leaders of healthcare systems need to become skilled at the practical application of all three sciences.

Medicine relies almost exclusively on the first science; consequently doctors often lack in-depth under-

standing of the other two.

P Thomas, G Meads, A Moustafa et al428

Europe now commonly emphasise community par-

ticipation, interprofessional learning and collaboration

across the public and independent sectors. 8

The national

clinical director (England) believes that PBC could be a

good vehicle to achieve comprehensive primary health

care. 9

This paper describes models that could help PBC to achieve this.

Meads’ research into ideal types of primary care organisation

Many models of primary care organisation have arisen

out of the inspiration of Alma Ata. In the UK, com-

munity oriented primary care, 10

and ‘Healthy Cities’

are two well-known examples. 11

But there has been little

research into ideal types of primary care organisation

that might help to realise an Alma Ata vision. The

concept of ‘ideal type’ is associated with the sociologist

Max Weber. It is useful because it stresses those elements that are common to a particular type, pro-

viding a ‘unified analytical construct’. 12

To an extent, the

various effects of a particular type can be predicted,

including their effects on integration. In reality, every

organisation is a hybrid of different types, but within

these hybrids, ideal types can be discerned. Commis-

sioners can choose to strengthen one or another type

to change the overall effect of their existing strategy for

integration. To help make sense of primary care organisation in

the 21st century, Meads visited and studied primary

care developments in 31 countries that were under-

going major healthcare reforms. 13

This led him to

examine in detail 24 case studies that illustrated the

broader principles of different types. This extensive

study presents the most authoritative contemporary

examination of different types of organisation of primary care. We summarise Meads’ case studies in

Box 3. Meads identified six ideal types of primary care

organisation. Below, we synthesise and analyse these

ideal types to propose three different models of com-

prehensive integration. These are not mutually ex-

clusive, and PCTs and PBC may use components of

different models in ways that are locally relevant. In

order to avoid bias, two authors (PT and KS) analysed Meads’ work in advance of inviting him to join us as a

co-author. Meads agreed with our analysis of his work,

enhancing the validity of our interpretations.

Box 3 Summary of Meads’ six ideal types of primary care organisation13

Starting in 2002, Geoff Meads and his research team at Warwick University visited 31 countries over the

course of the next four years. He was looking to make sense of primary care in the 21st century and focused on novel organisational forms. He wrote 24 case studies that illustrated six ideal types of primary care

organisation. Here we provide a brief summary of these to support our use of his work when proposing

models of combined vertical and horizontal integration of healthcare effort.

1 The outreach franchise: examples are Manila (Philippines), Medan (Indonesia), Tokushima (Japan) and Shanghai (China). In this model a central hospital or administrative agency commissions charities,

companies, churches, councils and communities to deliver primary care. There is rarely coherence between the

pattern of service delivery in one area and another. Aside from the requirements of any specific contract,

both vertical and horizontal integration are ad hoc and largely dependent on visionary leaders and chance.

2 The reformed polyclinic: examples are Singapore, Copacabana (Brazil), Sydney (Australia) and Santiago

(Chile). The model originated in Russia as part of centralised planning for health care. It now attracts

international interest as a way for specialist and generalist doctors to connect at local level without the need

for co-ordinated service planning. Doctors convene, usually in the same building, and are paid for what they do, either directly by patients or through government subsidy. Vertical integration dominates with an

emphasis on medical treatment of individual problems. But the overall value of a polyclinic must be

interpreted in the light of other local services and the vision of the doctors. For example, in Sydney there is a

strong parallel public health role in health promotion, whereas in Copacabana the polyclinic functions

almost as a community development agency.

3 The extended general practice: examples are Kangasala (Finland), Viseu (Portugal), Anogia (Greece) and

Wimborne (England). The examples cited are larger than the average UK general practices, with up to

20 GPs serving up to 32 000 people. The smallest (9000 patients) was only this size because of the low population within its large rural area. It finds its roots in post (2nd world)-war general practice that became

separated from hospital development and identified with community services. It strongly emphasises

multidisciplinary working. It facilitates horizontal integration through its extended multidisciplinary

team, since inter-organisational partnerships are usually too weak to support broader collaborations. It

facilitates vertical integration by gate-keeping specialist care for those registered with the practice. GPs

have pivotal leadership roles, often shared with other team members. A health authority manages the

Combined horizontal and vertical integration of care 429

Three models of comprehensive primary health care

At three different stages of NHS evolution, Meads’ six

ideal types naturally group into three pairs, each of which provides a model of combined horizontal and

vertical integration. We examine these three models,

highlighting options for PBC.

Model 1: Outreach franchise and polyclinic – integrating through medical practice

Outreach franchise was the status of general practice

immediately after the invention of the NHS in 1948. GPs were independent contractors paid a fee for every

patient on their list – but what they did was largely left

up to them. The polyclinic bears comparison with the

community hospital that was also a feature of the NHS

contract for services through certain markers of achievement, and negotiates practice involvement in local

developments.

4 The district health system: examples are Pallisa (Uganda), Mathbestad (South Africa), Medelin (Columbia)

and Prague (Czech Republic). This model has been promoted by the WHO as a way to provide whole

population care. Its philosophy is ‘health for all’ but its organisation is bureaucratic, often stifling innovation. A health authority employs all healthcare workers and public health officers. It is customarily

part of a wider multidepartmental executive with responsibility for the full spectrum of public facilities

across populations from 10 000 to 100 000 plus. Nurses commonly run clinics with doctors operating

as supervisors or strategic consultants. Both vertical and horizontal integration are planned through

committees that devise care pathways and cross-organisational innovation. Line management is the norm,

but often at a local level charismatic nurses act as community leaders in their ‘spare time’ – this

entrepreneurial interface with voluntary work and community development is largely invisible in

published papers. 5 The managed care enterprise: examples are Puebla (Mexico), Auckland (New Zealand), Calgary (Canada)

and Ayulthaya (Thailand). This form of organisation was developed in North America to bring everything

to do with disease management under the control of one health insurance company. Family physicians are

contracted by insurance companies to deliver agreed packages of care. The model is being adopted

throughout the developing world as a condition of international loans. It has also found favour in many

developed countries, including England, as a way to contain the cost of specialist services. Its philosophy is

rooted in market theory, focusing on ways to control waiting times, prescriptions, diagnoses and packages

of care. Those who purchase services are often separated from those who provide them, to make one accountable to the other. League tables of performance are analysed in public. Deviation from the norm

results in financial sanctions. Vertical integration of medical care is its great strength, being able to track

and cost all links in the chain of a care pathway. Horizontal integration is present or absent depending on

traditional contexts, but difficulties in measuring this can result in it being misrepresented. The term

‘horizontal integration’ is used to mean local management of medical conditions. The model has been used

in a co-operative way, but management is firmly focused on the bottom-line of cost.

6 The community development agency: examples are Chiclayo (Peru), Libertador (Venezuela), San Hose

(Costa Rica) and La Paz (Bolivia). This model carries with it a concern for social justice and sees ‘health as a citizen, rather than professional issue’. Basic principles include capacity building, shared responsibility

and local ownership. It aims for simultaneous vertical and horizontal integration. Centres serve popu-

lations of 10 000–20 000. Local multidisciplinary committees develop economic policies that include

control of pharmaceutical supply and local pricing, also using mapping techniques and community

diagnosis to evaluate social capital. A network of co-operatives and neighbourhood committees support

sophisticated horizontal integration of healthcare effort. Women and elders particularly became leaders

within these groups. The approach is overtly connected with the notion of a learning organisation, and

practitioners are often required to take part in learning events such as telemedicine link-ups with a university hospital. Local autonomy is tempered by a national weighted allocation formula to achieve

national equity and targets for capital investment. Integrated information systems facilitate the amalga-

mation of data. Public health and personal care practitioners work side by side. Management concentrates

especially on communication systems.

P Thomas, G Meads, A Moustafa et al430

at that time – here specialists rubbed shoulders with

GPs, and their patients lay side by side in adjacent

beds. Together these provided a model of vertical

integration – from general medical practice to specialist

medical practice.

Our NHS Our Future signals a re-visitation of the polyclinic idea to enhance vertical integration, as a form

of intermediate care where specialists and generalists

can meet. 14

Professor Lord Darzi, its author, stresses

that he uses the term ‘polyclinic’ to mean more than

vertical, medical integration. He said in an interview

with one of this paper’s authors (PT): 15

‘I strongly believe we must get together people from these

different health care settings, which are historically built

around primary, secondary, and tertiary ... and colleagues

doesn’t mean just medical colleagues, it means nursing

colleagues ...

... Let me put on record. Polyclinics are not buildings.

Polyclinics are my way of describing integrated service

provision ...

I think we all need to need to reach that maturity (of

leading ‘‘bottom up’’ developments). Not just the Depart-

ment of Health. Actually all the national organisations

need to think about bottom-up.’

The polyclinic model could be adapted to act as a

focus for horizontal integration. A polyclinic, whether

a large building or an integrated federation of primary

care organisations, could house teams of community

workers who plan a breadth of community activities, including multicultural events, projects that develop

social capital, self-help activities and international ex-

change. Cross-over planning between the vertical and

horizontal functions could lead to one-stop shops that

help local people to navigate whole systems of care.

Networks for research and clinical excellence could be

connected at a ‘polyclinic’, providing a way for uni-

versities to channel their local involvement. Recruit- ment into clinical trials could be led by this unit that

would negotiate a fee for this service to fund locally

led innovations and audit, in a similar fashion to the

approach adopted by Finland’s primary care centres. 16

Medical influence will be strong in this first model,

and this will inevitably emphasise a medical view of

health and disease. That may not be enough to realise

the broader aspirations of Alma Ata – that health is everyone’s concern.

Model 2: Extended general practices and district health systems – integrating through multidisciplinary teams

Extended general practice and district health systems

resemble UK arrangements after the 1990 healthcare

reforms when the focus of service delivery changed

from the individual GP to the multidisciplinary

general practice organisation. Nurses and allied health

professionals became employed by NHS ‘community

trusts’ that also managed hospitals. They attached

their staff to general practices to form extended teams,

and developed shared vision and mission through

residential team-building workshops. 17

An inter- organisational local organising team facilitated these

workshops and solved political problems. 18

This led

to enhanced ability to integrate in the horizontal

dimension, providing an infrastructure of facilitation

and communication to support interdisciplinary

innovation.

Multiple variations to the basic model were made

in those years, to enable creative interaction between activities in the vertical and horizontal planes.

19 In

Liverpool, local multidisciplinary facilitation teams

helped primary care teams to use action learning and

participatory action research to improve quality within

geographic areas; 20

working with the Healthy City

2000 project they brokered cross-city collaborations

for multiple projects that involved general practice

teams, specialists, city council, voluntary groups, schools, youth and community groups, trade unions and the

media. 21

In Sheffield, facilitators used data from GP

computers to support local reflection and action for

change. In South London a network of multidisciplinary

general practices provided local leadership for research,

audit, quality improvements and student placements.

The Kings Fund (London) led whole-system interven-

tions throughout the UK that enabled synchronised cross-organisational policy between health and social

care and the voluntary sector. 22

PBC could revitalise these models and from them

develop a powerhouse of multidisciplinary learning,

innovation and community development at local level.

This could provide a focus for ‘bottom-up’ leadership

of inquiry and action, to complement the more ‘top-

down’ approach that will naturally flow from Model 1.

Model 3: Managed care and community development agencies – integrating through networks

Managed care and community development agencies

are models that change the focus of service delivery

from individuals and discrete multidisciplinary pri-

mary care teams to whole systems of care. Both claim

to be models of comprehensive (whole-system) inte-

gration. But they conceptualise the task differently. The signal difference between managed care and

community development agencies is revealed in this

quotation from a leader of a Peruvian agency: ‘We see

health as a ‘‘citizen’’ not a ‘‘profession’’ issue’ (p.100). 13

Managed care uses the term ‘horizontal integration’ to

mean treatment in the community of named (medi-

cal) conditions. 23

A community development agency

Combined horizontal and vertical integration of care 431

locates the same term within its framework for

participatory democracy, which embraces all things to

do with being a healthy society, of which treating

diseases is merely a part.

Managed care therefore virtually ignores horizontal

integration as we have defined it. Instead it is a sophisticated version of vertical, targeted integration

– targeted at a comprehensive range of diseases.

Managed care and community development agencies

have quite different strengths and weaknesses. Man-

aged care uses sophisticated ways to track patient

movements and costs, but has limited ability to facil-

itate local learning and co-ordinated action for health.

By contrast, community development agencies are effective at enabling local learning and co-ordinated

action, but are comparatively slow at producing ‘top-

down’ direction, as this quotation reveals:

‘... while lay representations and contributions can be

significantly enhanced, so too can the power afforded

minorities, vested interests, corrupt cartels and even

unrepresentative community factions.’ 13

However, its ability to fashion a broad consensus and

to motivate those involved to ‘give back’ are major

strengths. Meads states:

‘it can go a long way towards ensuring that healthcare

expenditure and priorities become less of a political

burden for hard-pressed governments.’ 13

Both use networks and systems to connect a diversity of stakeholders. Managed care emphasises the role of

these in checking that agreements are understood and

adhered to. Community development agencies em-

phasise their use as a mechanism for co-ordinated

collaborative development.

Many advocate the managed care model for the

UK. 24

Systems to support it have already been devel-

oped. The Quality and Outcomes Framework, Dr Foster, Choose and Book, Payment by Results – these are

data-management systems that help to track patient

movements and costs. However, there is little evidence

within PBC plans of horizontal integration as it would

be defined by community development agencies. If

this is not added, as Mexico for example has discovered,

undue medicalisation appears inevitable, with all its

associated dangers, including excess professional spe- cialisation and regulatory capture, accelerating costs,

and reduced population health. 25,26

A model that integrates vertical and horizontal

activities might include features of both managed

care and community development agencies. Mean-

ingful interaction between those who see health as a

citizen issue and those who see it as a professional issue

is likely to resemble ongoing dialogue, more than hard-wired connection.

27 Participatory and whole-

systems approaches to research will be needed. 28

Discussion

Both Meads’ original work and our further analysis of

it, give commissioners a range of options to plan for

comprehensive integration. PBC aims for combined vertical and horizontal

integration, but dominant ways of thinking about

how to achieve these, coupled with inadequate train-

ing of NHS leaders (not only GPs), are likely to

emphasise the vertical dimension. In consequence,

PBC is in danger of achieving the opposite of its

purpose, replicating the mistakes of North America

and the WHO, 3

by paying too much attention to the medical aspects of health problems, and insufficient

attention to the processes of social cohesion.

Leaders must constantly assert a need for a mean-

ingful balance between the vertical and horizontal

dimensions, in pursuit of comprehensive primary

health care as envisaged at Alma Ata. 3

Further, they

must pilot mechanisms that enable vertical and hori-

zontal activities to helpfully mould each other through ongoing whole-system inquiries and action. This will

allow the parts (care of specific diseases) and the whole

(the health of individuals, communities and health-

care systems) to remain in tune with each other. 29

The

three models described above provide options to

achieve this.

An important take-home lesson from this analysis is

that combined horizontal and vertical integration can happen in a natural, evolutionary way when those

involved have time to think the issues through, and

when appropriate theories of change are used. Health

service policy must be careful to enable this, and avoid

heavy-handed micromanagement that prevents people

thinking and acting for themselves. They must re-

member that the best configuration depends on the

local political, cultural and historical context, and enable creative thinking at all levels. Lord Darzi, facilitator of

the present NHS reforms, has given a clear commit-

ment to this bottom-up approach. Whether this can

be practically realised will depend on the courage and

actions of all involved, and not merely his personal

determination.

Much is changing in a way that could make very

positive improvements in participation, equity and intersectoral collaboration. Already the theory and

practice of whole-system learning and change is being

introduced into the commissioning process. The prac-

tical work of developing local alliances for polyclinics

offers multiple opportunities for multidisciplinary

leadership teams to learn how to facilitate broad

participation in service developments. It would be

fitting, in the year that holds the 30th anniversary of Alma Ata and the 60th anniversary of the NHS, that

the UK NHS points the way towards much-needed

P Thomas, G Meads, A Moustafa et al432

models of comprehensive integration for health and

care.

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FUNDING

Support was received from a professor (KS) in receipt of a grant from the American Cancer Society.

PEER REVIEW

Not commissioned; externally peer reviewed.

CONFLICTS OF INTEREST

None.

ADDRESS FOR CORRESPONDENCE

Professor Paul Thomas, Ealing Primary Care Trust,

1 Armstrong Way, Southall, Middlesex OB2 4SA, UK.

Tel: +44 (0)20 331 39102; email: [email protected]

Received 29 June 2008

Accepted 9 October 2008